Errors of Omission and Commission

by Jamie Flinchbaugh on 06-02-20

In reading Russell Ackoff’s A Lifetime of Systems Thinking, he shared a key point about mental content that I think relates to lean systems in a way that reveals a weakness in many lean practices. 

Ackoff starts by exploring the hierarchy of mental content, which he orders as: data, information, knowledge, understanding, and wisdom. Not to get sidetracked, I think this is important as so much importance is put into data, and data science which is meant to hopefully turn that into information. But, I believe that little is done in such pursuits to develop true understanding or wisdom. Anyway, back to the point at hand…

He wants organizations to be better at learning (at all levels) as most systems thinkers do. He acknowledges that most organizational learning comes from mistakes, but talks about those mistakes in two different forms. First is the mistake of commission, which is doing what should have not been done. Second is the mistake of omission, which is not doing which should have been done. 

Most lean systems are set up to make problems visible. Whether it’s standard work, 5S, visual management, or daily huddles looking at KPIs, those are fundamentally designed to help make problems of commission more visible. These are less effective, in general, at making errors of omission more visible. If you use Leader Standard Work in your operation, much of it is finding errors where something is out of place or off standard. These are primarily commission errors. 

But are mistakes of omission just as obvious? Are we designing our work to make errors of omission visible? What are your major risks, and how will you know if something was NOT done?

I would really love to hear your comments on how big a risk you think this might be. Please share your perspective and experiences below.